Hysterectomy For Benign Indications Research Articles

2885 Endosee(R) Cystoscopy: An Alternative for Evaluating Ureteral Patency Following Total Laparoscopic Hysterectomy

Video Objective To demonstrate an alternative method to evaluate for ureteral patency following benign hysterectomy. Design This is a retrospective cohort study of ten patients undergoing cystoscopy following benign hysterectomy to assess for ureteral patency. Setting This study took place at a single academic institution in the inpatient setting. Patients or Participants Patients were included in the study if they underwent total laparoscopic hysterectomy for benign indications from February 2019 to April 2019. Interventions Five patients underwent cystoscopy with traditional 70 degree rigid 17 French cystoscope. Five patients underwent cystoscopy with Endosee. Measurements and Main Results We compared cost, time, diameter size, and amount of bladder distending fluid required in patients undergoing traditional cystoscopy versus Endosee cystoscopy. The average cost for traditional cystoscopy was $246 and $165 (not including cost for hand piece) per case for Endosee cystoscopy. The average time for set-up and procedure was 7-12 minutes and 3 minutes for traditional and Endosee cystoscopy, respectively. The diameter of traditional cystoscope was 5.7 mm and 4.8 × 4.2 mm of Endosee cystoscope. Traditional cystoscope required approximately 200-300 mL distending fluid versus less than 60 mL distending fluid with Endosee. Conclusion Endosee cystoscopy is an efficient and reliable way to evaluate ureteral patency following benign total laparoscopic hysterectomy.

1439 Feasibility and Surgical Outcomes Associated with Reduced Port Robotic-Assisted Hysterectomy

Study Objective Demonstrate the safety, feasibility, and outcomes associated with the reduced port robotic-assisted hysterectomy (RPRH). Design We performed a retrospective cohort study of women undergoing a reduced-port robotic-assisted hysterectomy between 2012 and 2018 for benign indications. Setting A single academic university hospital. Patients or Participants Women who underwent a reduced port robotic-assisted hysterectomy for benign indications by a fellowship trained minimally invasive surgeon. Interventions A reduced port robotic-assisted hysterectomy for benign indications. Measurements and Main Results Women included were stratified into one of four groups based on uterine weight: Conclusion Reduced port robotic-assisted hysterectomy is a safe, effective, and efficient surgery for appropriately selected women. Outcomes appear similar across uterine weights with increased operative time, estimated blood loss, and odds of ureterolysis increasing as specimen weight increases.

Cost Drivers for Benign Hysterectomy in a Healthcare System, 2013-2019

Study Objective To analyze the association of patient factors and surgical indications with hospital charges between hysterectomy approaches (laparoscopic, robotic-assisted, abdominal, and vaginal). Design Retrospective study from 7/2013–2/2019 using the Premier Healthcare Database (clinical and financial data from hospital-based outpatient and inpatient encounters). Comorbidities were assessed using the Elixhauser Index. Total charges adjusted for inflation using Consumer Price Index. Multivariate linear regression performed to identify factors affecting total charges. Setting Integrated healthcare system including five academic and community hospitals in one region. Patients or Participants 4,523 women age 18–88 years underwent hysterectomy for benign indications (fibroids, abnormal uterine bleeding [AUB], endometriosis, pelvic organ prolapse [POP], and other indications). Interventions N/A Measurements and Main Results Most common indication across all approaches was fibroids (50%), then AUB (17%), endometriosis (9%), POP (9%) and other diagnoses (15%). Median age was 47 years (IQR 42-52 years). The sample was 53% White, 35% Black, and 12% other races; 7% were Hispanic. 51% had no comorbidities, 25% had one comorbidity, and 24% had two or more. 28% were discharged on POD#0, 47% on POD#1, 14% on POD#2, and 11%% on POD#3 or later. Median charges were $11,908 for laparoscopic, $14,574 for robotic-assisted, $17,162 for abdominal, and $11,954 for vaginal. In regression, charges for hysterectomy were affected significantly by surgical approach, indication, year, age, race/ethnicity, comorbidities, length of stay, and hospital site (p Additional charges for robotic-assisted hysterectomy compared to laparoscopic were smallest for fibroids and greatest for POP. Laparoscopic hysterectomy was less expensive than abdominal only for endometriosis. Conclusion The added charges for a robotic-assisted laparoscopic approach can be minimized if employed for appropriate benign surgical indications, particularly fibroid uteri.

2180 Experience of Centro Medico Nacional “20 De Noviembre“ in Robotic-assisted Hysterectomy for Large Uteri: A Case Series of 20 Women

Study Objective To determine the outcomes of robotic-assisted laparoscopic hysterectomy for benign conditions in women with large uteri. Design A prospective and recruting cases for robotic-assisted laparoscopic hysterectomy for benign indications at Centro Medico Nacional “20 de Noviembre” by one surgeon with trainning in minimally invasive and Robotic surgery between May 2016 to August 2018. Setting Centro Medico Nacional “20 de Noviembre” ISSSTE. Patients or Participants Only women with large uteri (defined as greater than 750g) were included in this study. Interventions Robotic hysterectomy. Measurements and Main Results A total of 20 women were included in the analysis: 11 patients had uterine weights 750-999g and 9 had uterine weights greater than 1000g with the largest being 1,450g. The average surgical times were 131 min (53-301 min) and 156 min (82-338 min), respectively. The average estimated blood loss was 50cc; no blood transfusions were required. There were no intra- operative conversions. There were none major intraoperative complications. There were 2 minor postoperative complications (acute urinary retention and a wound dehiscence of an umbilical port site); both were in the 750-999g group. All patients in both groups were hospitalized 0-1 days. Conclusion In skilled hands, robotic-assisted laparoscopic hysterectomy in women with large uteri is an acceptable option, associated with minimal complications.

Intra-operative Factors Identified During Laparoscopy Hysterectomy are Correlated With Increased Post-operative Pain and Opioid Use

Study Objective To identify intra-operative factors during laparoscopic hysterectomy associated with post-operative opioid use and pain scores Design Prospective cohort study of women undergoing laparoscopic hysterectomy. Primary outcome was the total amount of opioids utilized during the first 2 postoperative weeks. Secondary outcomes were the subjective pain score at 1 and 2 weeks after surgery. This is a secondary analysis of this dataset. Setting Two academic community teaching hospitals in the Boston metropolitan area Patients or Participants 125 women ages 30-76 undergoing hysterectomy for benign indications performed by minimally invasive gynecological surgeons Interventions All patients received a prescription for post-operative opioid medication. Surveys were administered at 1 week post-op and in-person at their two week postoperative visit and focused on pain scores (visual analog scale) and medication use (converted to morphine milligram equivalents (MME). Measurements and Main Results Participants were prescribed a median of 150 MME, however the median total opioid use was 37.5 MME (range 0-960 MMEs). Patients with pathology confirmed endometriosis required more than twice the total MME during the first 2 weeks compared to patients without endometriosis (mean 193 vs 95 MME, p =0.031). Patients with fibroids used significantly less total MME during the acute post-operative period compared to those without fibroids (mean 89.5 vs. 183.3 MMEs, p = 0.002) and reported significantly less pain at week 1 and 2 (p = 0.05). Adenomyosis, length of surgery, BMI, uterine weight and blood loss were not significantly correlated with total MME. Conclusion Several factors, easily recognized intra-operatively, may be predictive of opioid requirements during the acute post-operative period. This can allow surgeon to set expectations and dispense narcotic prescriptions that are patient specific. Individualizing prescriptions instead of merely writing standard amounts of opioids will lower the amount of excess circulating opioids and help combat the opioid epidemic. Further research is needed to validate this data in a larger population.

1957 Robotic Assisted Mesh Removal: Posterior Vaginal Mesh Kit and Perivesical Mesh Invading Obturator Internus

Video Objective This video depicts a surgical approach in a patient with both a complicated and unclear surgical history, with inability to obtain complete surgical record. It demonstrates a robotic assisted laparoscopic approach to removal of mesh in a patient with persistent pelvic pain with an unclear or unknown mesh location. Setting This is a 60 year old woman with a remote history of hysterectomy for benign indications. Per patient, she subsequently developed symptomatic prolapse for which she underwent a “bladder sling” and two “hernia repairs” which necessitated suprapubic catheter post-operatively. She then experienced worsening pelvic pain since that time, now years later, and with constant rectal pressure and more recent post-coital bleeding. The patient is adamant on complete mesh removal. This was performed as an ambulatory surgery within a hospital setting. Interventions Pelvic examination revealed noticeable tenderness of anterior vaginal wall, with no exposed mesh or bleeding. The video itself depicts a robotic assisted laparoscopic removal of bilateral posterior vaginal mesh kit and left perivesical mesh invading obturator internus. Careful surgical technique involving bladder dissection off vaginal cuff, ureterolysis, and dissection throughout the space of Retzius down to the obturator internus muscle is carried out with complete removal of multiple mesh components. Conclusion Avoiding transection of the mesh along with meticulous dissection aides in traction and greatest chance of complete removal. Maintenance of hemostasis is critical for adequate visualization, especially within the space of Retzius. Knowledge of pelvic anatomy is paramount, as scarring, fibrosis, and mesh migration can distort normal anatomical planes.

Perioperative Narcotic Trends in Women Undergoing Minimally Invasive Hysterectomy for Benign Indications

Study Objective Evaluate the utilization patterns for narcotic medication both intraoperatively and postoperatively at the time of benign minimally invasive hysterectomy, specifically as they relate to the opioid epidemic. Design Retrospective cohort study. Setting A single academic university hospital. Patients or Participants Women undergoing minimally invasive hysterectomy for benign indications. Interventions Laparoscopic or Robotic-Assisted hysterectomy. Measurements and Main Results 651 hysterectomies were included in the analysis between 2012 and 2018. For consistency all narcotics administered intraoperatively and in immediate postoperative period were converted to mean morphine equivalents (MME). For the entire cohort the mean age was 44.5 ± 7.4 years and the mean Body Mass Index (BMI; Kg/m2) was 32.1 ± 7.6. Of these, 377 hysterectomies (57.9%) were performed with robotic assistance and the remainder (42.1%) were performed using conventional laparoscopy. A statistically significant inverse relationship was found between the year of surgery and perioperative narcotic usage (p=.007). In all hysterectomies analyzed yearly MME use decreased over time (p Conclusion Perioperative narcotic use has down trended over time for patients undergoing minimally invasive hysterectomy. Hysterectomy performed with robotic assistance was associated with lower postoperative narcotic use compared to conventional laparoscopy.

Comparison of 30-Day Complication Rate Between Minimally Invasive Hysterectomy with and Without Concomitant Urogynecologic Procedure

Study Objective Primary objective was to evaluate risk of perioperative complications when performing concomitant urogynecologic surgery at time of minimally invasive hysterectomy for large uterus (>250gm). Design Retrospective cohort study of existing national database. Patients were followed for complications 30 days after hysterectomy. Setting Data was extracted from the NSQIP database. Patients or Participants Patients were included who underwent laparoscopic or vaginal hysterectomy for benign indications with uterine weight of at least 250gm from 2014-2017. Patients with gynecologic malignancy and those who underwent abdominal hysterectomy were excluded. The total cohort included 7,428 patients. Interventions We assessed the effect of concomitant urogynecologic procedure on 30 day complication rates after laparoscopic or vaginal hysterectomy for large uterus (>250gm). Measurements and Main Results Chi-square analysis and Student's t-test were used to describe the population and compare groups. Primary outcome was composite rate of all 30 day complications. Stepwise backward multivariate logistic regression was used to control for confounders of the primary outcome. 301 of the 7,428 total patients (4.1%) underwent concomitant urogynecologic procedures. This population was older (49.7 vs 46.6 years, p Conclusion In this retrospective analysis of a large national cohort, the 30 day complication rate was greater than 50% higher when concomitant urogynecologic procedure was performed at the time of minimally invasive hysterectomy for a uterus >250gm.

Typical Opioid use After Minimally Invasive Hysterectomy

Study Objective To describe typical narcotic requirements after benign minimally invasive hysterectomy and evaluate patient risk factors for higher narcotic use. Design In a prospectively collected data set as part of a randomized controlled trial comparing single-dose preoperative gabapentin use to nonusers, women undergoing a benign minimally invasive hysterectomy were assessed for total narcotic use and subjective pain scores at 2 weeks postoperatively via phone. Results from this trial resulted in no difference between groups, therefore the data set was utilized to assess typical narcotic use at 2 weeks postoperative. Total narcotic use was then compared across surgical specialties (generalist, urogynecology, minimally invasive gynecology [MIGS]). Patient demographics and operative details were compared between top quartile users versus regular users. Setting Single academic affiliated community hospital. Patients or Participants From June 2016 to June 2017, women undergoing hysterectomy for benign indications via a minimally invasive approach were approached to participate. Inclusion was limited to patients of high volume surgeons (more than 20 hysterectomies annually) within the generalist, MIGS, and urogynecology divisions. Women were excluded if known to have a contraindication to gabapentin, acetaminophen, or celecoxib use, or if their procedure was converted to laparotomy for any indication. Interventions N/A Measurements and Main Results A total of 109 women had data at 2 weeks postoperative to be analyzed for cohort analysis. The median oral narcotic requirement was 40 morphine milligram equivalents [MME] (interquartile range 0 – 96). Patients undergoing surgery with MIGS providers required less postoperative narcotics than those with a generalist trained surgeon (15 MME versus 75 MME, p = 0.007). Younger age and prior laparoscopic surgery were also found to be associated with high narcotic utilization after benign hysterectomy. Conclusion Typical oral narcotic requirements after benign minimally invasive hysterectomy are minimal with median use equivalent to approximately five tablets of oxycodone (5 milligrams).

Incidence and Predictors of Persistent Pelvic Pain Following Hysterectomy in Women with Chronic Pelvic Pain

Study Objective To describe the incidence and risk factors for persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain (CPP). Design Prospective, observational cohort study of women with chronic pelvic pain undergoing hysterectomy. Setting Academic tertiary care center. Patients or Participants 126 women with CPP undergoing hysterectomy for benign indications. Interventions Patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 fibromyalgia survey criteria, 0-31 points) preoperatively and 6-months after hysterectomy. Demographic information, surgical history, intraoperative findings and surgical pathology were abstracted from the electronic medical record. Preoperative CPP was defined as average pelvic pain ≥3/10 for >3 months. Multivariate logistic regression was used to identify independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as Measurements and Main Results Among 176 participants with CPP, 126 (71.6%) were retained at 6-months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (p=0.46), race (p=0.55), pain severity (p=0.10) or pain duration (p=0.80) in those with and without persistent pelvic pain. While intraoperative findings of endometriosis (p=0.045) was associated with a higher incidence of persistent pain, surgical route (p=0.46), uterine fibroids (p=0.34), adenomyosis (p=0.23), pelvic adhesions (0.51), uterine weight (p=0.66) were not related to risk of persistent pain. Higher preoperative centralized pain scores (p=0.01), but not depression (p=0.13) or anxiety (p=0.28) were more common in women with persistent pelvic pain. Multivariate logistic regression controlling for age, anxiety, and endometriosis indicated that every 1-point increase in centralized pain was associated with a 23% increase in odds of persistent pelvic pain (OR 1.23, 95%CI 1.03, 1.48). Conclusion While the majority of women with CPP report considerable improvement in pain following hysterectomy, higher degrees of centralized pain prior to hysterectomy is a robust predictor of persistent pain, even among women whose score falls below the diagnostic criteria for fibromyalgia.

3014 Examining Disparities In Route Of Hysterectomy for Benign Indications within an Integrated Healthcare SysteM

Study Objective Racial disparities exist in routes of benign gynecological surgery within the United States. Compared to open abdominal hysterectomies, minimally invasive hysterectomies (MIH), including laparoscopic, vaginal, and robotic, reduce pain, blood loss, and recovery time. We questioned if such disparities would be mitigated within an integrated healthcare system. Design Data-only retrospective single-institution cohort study. Setting A metropolitan-based integrated health system surgical center. Patients or Participants Between 2008 to 2015, 31,385 women underwent hysterectomies. Preoperative malignant indications or pregnancy related procedures were excluded. During this period, our surgeon pool strategically decreased by nearly half. Interventions N/A Measurements and Main Results Unadjusted odds ratios (OR), adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) were estimated using the simple logistic regression for the crude association between MIH and individual risk factors (Black race, uterine weight [proxy for fibroids], low income, and medical benefit plan), and multivariable logistic regression analyses for the additive effect of risk factors. Among the study population 49% were White, 13% Black, 21.4% Hispanic, 11.5% Asian, and 5.1% other. 72.9% were MIH, of those 74.5% were White and 65.8% were Black (P Conclusion Within an integrated healthcare system, racial disparities are markedly reduced when compared to other settings Our high-volume, uniform teams likely aided this outcome. Further research is needed to identify determinants of racial disparities.

1369 Cost and Outcomes Analysis of Robotic, Laparoscopic, and Abdominal Hysterectomy for Benign Disease in a Community Hospital Setting

Study Objective To compare overall costs and quality measures of various methods of benign hysterectomies at a community based hospital system Design A retrospective review of all hysterectomies for benign indications at Saint Peters University Hospital between March 2017 to Dec 2018. Robotic assisted laparoscopic hysterectomies, laparoscopic hysterectomies, and abdominal hysterectomies were compared. Setting Data was collected from admission to discharge. In the OR, all patients were in comparable sized OR rooms and staff were trained in the procedure performed. Patients undergoing robotic assisted hysterectomies and laparoscopic hysterectomies were placed in the dorsal lithotomy position with trendelenberg. Those undergoing abdominal hysterectomies were placed in the dorsal supine position. Patients or Participants The study included 288 women who underwent benign hysterectomy by any method at Saint Peters University Hospital from March 2017 to Dec 2018. 86 (40.4%) patients underwent a robotic assisted laparoscopic hysterectomy, 60 (28.0%) underwent a laparoscopic hysterectomy, and 68 (31.7%) underwent an abdominal hysterectomy. Interventions All patients received a hysterectomy in one of the three following methods: robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy, and abdominal hysterectomy. Concomitant procedures of a salpingo-oophrectomy and/or cystoscopy were performed if indicated. Measurements and Main Results A retrospective chart review was performed for all benign hysterectomies from March 2017 to December 2018 using student t test and a multivariate regression analysis. The primary outcome was the direct total cost of the patient's hospitalization related to their hysterectomy. Secondary outcomes included estimated blood loss, surgery time, days in the hospital postoperatively, and complications postoperatively. Mean total costs of robotically assisted hysterectomies were $26,452 less than abdominal hysterectomies (p Conclusion Overall, total cost was significantly influenced by the mode of hysterectomy, with robotic assisted hysterectomies being the most cost effective.

2897 Sleep, Fatigue, and Life Satisfaction After Hysterectomy in Women with Preoperative Pain and Depression

Study Objective To examine differences in life satisfaction, sleep, and fatigue after hysterectomy among women with preoperative pelvic pain and/or depression. Design Secondary data analysis of a prospective, observational cohort study of women undergoing hysterectomy for benign conditions. Setting Academic tertiary care center. Patients or Participants 336 patients undergoing hysterectomy for benign indications. Interventions Patients completed validated assessments of life satisfaction, sleep, and fatigue preoperatively and 6-months after hysterectomy. Patients were divided into four groups based on preoperative characteristics: pelvic pain only, depression only, pain + depression, and no pain or depression. Presence of pelvic pain was defined as average pelvic pain score of ≥ 4 (on numerical rating scale 0-10) at baseline survey. Measurements and Main Results Preoperatively, women with pelvic pain only reported worse sleep (p=0.01) and fatigue (p At 6-month follow-up, women with pelvic pain only reported significant improvements in life satisfaction (p=0.04), sleep (p Conclusion Women with pre-existing pelvic pain only demonstrate improvements in life satisfaction, sleep disturbance, and fatigue following hysterectomy and achieve similar levels to those with no pain or depression. Women with coexisting depression fare significantly worse in these domains than those without.

1235 Myometrial Cells in Pelvic Washings at time of Benign Hysterectomy

Study Objective To evaluate if smooth muscle cells can be detected in pelvic washings at time of intact hysterectomy. Design A multi-centered pilot cohort study. Setting Two academically affiliated tertiary referral centers. Patients or Participants Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. Interventions Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, slides were stained using hematoxylin and eosin (HE three subjects were excluded due to unplanned morcellation. Smooth muscle uterine cells were detected in 1 pre-wash specimen and 2 post-wash cases. The group with positive washings was noted to have longer procedure time (136 minutes versus 114 minutes), lower blood loss (25 mL versus 86 mL) and higher uterine weight compared to negative washings group (242 grams versus 234 grams). Conclusion Tissue dissemination of uterine cells may be possible at time of hysterectomy. Larger prospective studies are needed in order to better describe the incidence of and risk factors for tissue dissemination.

Superior Hypogastric Plexus Block for Pain Relief After Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study Objective To assess the efficacy of a superior hypogastric plexus block (SHPB) for pain relief following laparoscopic hysterectomy. Design Multi-center, single-blind, randomized controlled trial. Setting Brigham and Women's Hospital, Boston, MA, University of North Carolina Medical Center, Chapel Hill, NC, and George Washington University Hospital, Washington, D.C. Patients or Participants 100 patients undergoing laparoscopic hysterectomy for benign indications were recruited between January 2018 and February 2019. Interventions Patients were randomized to receive a SHPB (n = 50) or no block (n = 50) at the start of laparoscopic hysterectomy. The block contained 10 mL of 0.25% bupivacaine injected in the presacral space. Measurements and Main Results The proportion of patients with a mean VAS (visual analogue scale) pain score less than 4 within 2 hours postoperatively was defined a priori as the primary outcome and compared between the groups. An intention to treat analysis was performed. Patients in the SHPB group were 1.6-times more likely to have a mean VAS Conclusion SHPB reduces immediate postoperative pain after laparoscopic hysterectomy however this effect does not extend to two hours postoperatively. SHPB does not impact opioid consumption, long-term pain, or recovery unit time.

Effect of Attending Mentorship Program on Physician Confidence Performing Laparoscopic & Vaginal Hysterectomies [2I

INTRODUCTION: Hysterectomies for benign indications have become increasingly performed by fellowship-trained Subspecialists, possibly due to the lack of mentorship among surgeons. We sought to evaluate the change in confidence level of Specialist Attendings (Sas) with the enactment of an Attending Mentorship Program (AMP) for laparoscopic hysterectomies (LHs) and vaginal hysterectomies (VHs). METHODS: Sas were invited to participate in this IRB-approved study. Baseline and 6-month post-AMP confidence levels were obtained using a Visual Analog Scale (VAS). LH mentors were members of the MIGS Division. VH mentors were members of the FPMRS Division. Secondary outcomes of operative time, estimated blood loss (EBL), length of admission (LOA), and postoperative complication rates were recorded. RESULTS: Thirteen Sas met inclusion criteria for this study and agreed to participate. From July 1st, 2017 to December 31st, 2017, 12 of these surgeons participated in the AMP performing a total of 35 hysterectomies. Ten Sas performed 27 LHs; seven Sas performed eight VHs. VAS scores increased 1.05 cm (p = 0.002) for LHs and increased 0.34 cm (p = 0.33) for VHs. The differences in operative time and EBL were not statistically significant in the AMP groups compared to the non-AMP groups. LOA and postoperative complication rates were similar between all groups. CONCLUSION: Confidence levels of Sas in performing LHs increased when the AMP was implemented. Though an increase in VAS confidence scores for VH was seen, this was not statistically significant. Mentoring can be an important factor in SA hysterectomy confidence.

Residents at Inner-City Academic Centers May Fail to Meet the New Minimally Invasive Hysterectomy Requirements [14P

INTRODUCTION: The ACGME and ACOG promote the use of minimally invasive approaches for hysterectomy. In 2018, the ACGME Ob/Gyn Residency Review Committee increased the number of minimally invasive (MIS) hysterectomies required for trainees to graduate residency. Historically, inner-city black women have higher rates of fibroid disease and other medical co-morbidities that may exclude MIS as the safest mode for hysterectomy. METHODS: Retrospective cohort study using the 2016 hysterectomy-specific National Surgical Quality Improvement Program (NSQIP) database. Demographics, comorbidities and surgical characteristics were examined by hysterectomy type. The association between race and hysterectomy type was investigated using one and two-way analysis of variance (ANOVA). RESULTS: In 2016, 20,770 hysterectomies for benign indications were identified. Across all races, 25.7% underwent abdominal hysterectomy, 57.4% underwent laparoscopic hysterectomy and 16.9% underwent vaginal hysterectomy. Black women were more likely than white women to undergo open abdominal hysterectomy (41.4% vs 20.1%, respectively, P<0.001). After adjusting for uterine weight (0-100 g, 100-250 g, and >250 g), black women were still more likely to undergo abdominal hysterectomy compared to other races (P<0.001). Additionally, when adjusting for history of prior abdominal or pelvic surgeries, black women were more likely to undergo abdominal hysterectomy compared to other races (P<0.001). CONCLUSION: Black women disproportionately undergo higher rates of abdominal hysterectomy compared to other racial groups. Trainees at academic medical centers with a higher proportion of black patients may fail to meet the number of minimally invasive hysterectomies required for graduation. Further efforts to identify the etiology of racial disparities in route of hysterectomy should be pursued.

Can the New ACGME RRC Hysterectomy Requirements Be Fulfilled at Inner City Academic Centers? [3L

INTRODUCTION: The ACGME and ACOG promote the use of minimally invasive approaches for hysterectomy when feasible. In 2018, the ACGME Residency Review Committee increased the number of minimally invasive (MIS) hysterectomies required for trainees to graduate residency. METHODS: Retrospective cohort study using the 2016 hysterectomy-specific National Surgical Quality Improvement Program (NSQIP) database. Demographics, comorbidities and surgical characteristics were examined by hysterectomy type. The association between race and hysterectomy type was investigated using one and two-way analysis of variance (ANOVA). RESULTS: 20,770 hysterectomies for benign indications were identified. Across all races, 25.7% underwent abdominal hysterectomy, 57.4% underwent laparoscopic hysterectomy and 16.9% underwent vaginal hysterectomy. Black women were more likely to undergo abdominal hysterectomy than white women (41.4% vs 20.1%, respectively, p<0.001), and less likely to undergo both laparoscopic and vaginal hysterectomy (47.5% vs 61.9% and 11.1% vs 18.0%, respectively, p<0.001). After adjusting for uterine weight (0-100g, 100-250g, and >250g), black women were still more likely to undergo abdominal hysterectomy compared to other races (p<0.001). Additionally, when adjusting for history of prior abdominal or pelvic surgeries, black women were more likely to undergo abdominal hysterectomy compared to other races (p<0.001). CONCLUSION: African American women disproportionately undergo higher rates of abdominal hysterectomy compared to other racial groups. Trainees at academic medical centers with high-risk and higher proportion of African American patients may experience difficulty fulfilling the number of minimally invasive hysterectomies required for graduation. Further efforts to identify the etiology of racial disparities in route of hysterectomy should be pursued.

Medical management prior to hysterectomy for benign indications: Trends from a tertiary-care centre

Medical management prior to hysterectomy for benign indications: Trends from a tertiary-care centre

Incidence and risk factors of postoperative ileus after hysterectomy

Objective Investigating the incidence and risk factors of postoperative ileus after hysterectomy for benign indications and the impact of postoperative ileus on surgical outcomes. Methods All patients who underwent hysterectomy for benign indications in Southern Hospital from January 1, 2013 to December 31, 2017 were included in this study. Patients who met the following criteria were deemed to experienced postoperative ileus: ① The signs of restoration of bowel function (passage of flatus or defecation) cannot be noted within 2 postoperative days. ② Symptoms of bowel dysfunction (nausea/vomiting or abdominal distention) were presented. Incidence and risk factors of postoperative ileus was investigated through statistical analysis. Surgical outcomes between patients with or without postoperative ileus were compared. Results A total of 1 017 cases were included in this study, including 432 laparotomy hysterectomy, 523 laparoscopic hysterectomy and 62 vaginal hysterectomy. Overall incidence of POI was 9.2%. Incidence of POI did not differ significantly in three different surgical approaches (abdominal hysterectomy 10.6%, laparoscopic hysterectomy 7.8%, vaginal hysterectomy 11.3%, P>0.05). Patients who developed postoperative ileus had prolonged hospital stay and increased risk of postoperative complications. Independent risk factors identified by multivariate logistic regression included history of malignant disease, dysmenorrhea, way of anesthesia, pelvic adhesion and operative time. Conclusions Postoperative ileus causes undesirable consequences to post-surgical recovery. Identifying risk factors of postoperative ileus facilitates identifying high risk patients. Aggressive preventive strategy should be used on such patients to decrease the incidence of postoperative ileus. Key words: Hysterectomy; Postoperative ileus; Risk factor